Major common bile duct injury and risk of litigation:
a surgeon’s perspective
Christophe R. Berney, M.B., M.D., Ph.D.*
University of New South Wales, Department of Surgery, Bankstown-Lidcombe Hospital, Bankstown, Australia
Abstract. Risk for a lawsuit for medical malpractice has unfortunately become part of physicians’ daily
professional activities, with a blowout in indemnity insurance premiums, especially in high-risk
medical specialties. Common bile duct injury following laparoscopic cholecystectomy is a well-
recognized and feared complication for surgeons because of its associated morbidity, and it also ranks
among the leading sources of medical malpractice claims against surgeons in the world. The purpose
of this article is to raise awareness within the medical community and in particular among specialist
surgeons on the important threat they could be facing in terms of litigation in the event of an adverse
surgical outcome following such a commonly performed procedure. There is a real need for open debate
on this concerning topic, as the fear of lawsuits and exorbitant malpractice premiums are pushing a
substantial number of medical professionals to practice defensive medicine, reflected by the avoidance
of performing certain procedures or treating high-risk patients perceived to have higher litigation rates,
or simply walking away from their current practices, creating a chronic shortage of specialized doctors
in certain surgical areas.
© 2011 Elsevier Inc. All rights reserved.
Bile duct injury;
Risk of litigation;
Laparoscopic cholecystectomy (LC), introduced in the
late 1980s, gained wide acceptance and rapidly became the
treatment of choice for symptomatic gallstone disease and
soon after for cholecystitis, mainly because of the signifi-
cant improvement in overall morbidity, shorter hospital
stays, and earlier return to work for patients. During the
initial phase of its development, a quasi-epidemic of com-
mon bile duct (CBD) injuries was reported1and conse-
quently rapidly brought to the attention of the surgical
community to act against it. Since then, with the refinement
of this technique, better teaching, and improved instrumen-
tation, the risk for iatrogenic CBD injury has progressively
reduced and plateaued. Unfortunately, it still remains higher
than for open cholecystectomy, with an estimated incidence
of .25% to .5% in the United States, where ?750,000 cases
of LC are performed each year.2Identical figures are pub-
lished around the world.
No one is immune from the risk for injuring the bile duct,
even experienced surgeons,3and as such, this will always
remain a significant inherent risk of this procedure. Some
have shown that the vast majority of errors leading to
laparoscopic CBD injury arise from visual-perceptual illu-
sions, not from errors of technical skill, knowledge, or
judgment.4Nevertheless, iatrogenic CBD injury still re-
mains the worst complication of LC, associated with sig-
nificant morbidity, reduced long-term survival,5and im-
paired quality of life,6and it ranks among the leading
sources of medical malpractice claims against surgeons in
the “developed” world, mainly in countries with a strong
Anglo-Saxon emphasis on individual rights.
By law, every practicing surgeon must hold professional
liability insurance to offset the risk and costs of lawsuits
based on medical malpractice, which can be exorbitant.
* Corresponding author. Tel.: 612-9722-8000; fax: 612-9793-8140.
E-mail address: email@example.com
Manuscript received May 29, 2011; revised manuscript June 17, 2011
0002-9610/$ - see front matter © 2011 Elsevier Inc. All rights reserved.
The American Journal of Surgery (2011) xx, xxx